Alfonso del Arco

Ankle-brachial index in HIV infection

Prognosis for patients with the human immunodeficiency virus (HIV) has improved with the introduction of highly active antiretroviral therapy (HAART). Evidence over recent years suggests that the incidence of cardiovascular disease is increasing in HIV patients. The ankle-brachial index (ABI) is a cheap and easy test that has been validated in the general population. Abnormal ABI values are associated with increased cardiovascular mortality. To date, six series of ABI values in persons with HIV have been published, but none was a prospective study. No agreement exists concerning the risk factors for an abnormal ABI, though its prevalence is clearly higher in these patients than in the general population. Whether this higher prevalence of an abnormal ABI is associated with a higher incidence of vascular events remains to be determined.

Guía de práctica clínica de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) sobre el tratamiento de la tuberculosis

El esquema terapeutico de la tuberculosis pulmonar inicial recomendado por la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) es el siguiente: En la fase inicial se usa isoniacida, rifampicina y piracinamida con administracion diaria durante 2 meses. En pacientes VIH(+) e inmigrantes procedentes de zonas con tasa de resistencia primaria a isoniacida superior a 4% debe anadirse etambutol hasta disponer del estudio de resistencias. La segunda fase (continuacion): rifampicina e isoniacida con administracion diaria o intermitente durante 4 meses en la poblacion general y 7 meses en pacientes VIH(+) ( Las pautas de tratamiento de la tuberculosis resistente se basan en opiniones de expertos. Habria que utilizar una combinacion de farmacos de primera linea todavia utiles, farmacos inyectables y agentes alternativos, como las quinolonas. Se recomienda el uso de tratamiento directamente observado en aquellos pacientes que presenten especial riesgo de contagiosidad o de incumplimiento del tratamiento.

Durability of the First Antiretroviral Treatment Regimen and Reasons for Change in Patients With HIV Infection

Abstract Background To study the durability of the drugs and coformulations currently used in the first treatment regimen of antiretroviral therapy (ART) for HIV patients, and to examine the reasons for changing this medication. Methods A retrospective observational multicenter study of patients with HIV infection who started a first-line ART regimen between January 2007 and June 2010. The primary outcome variable was the durability of this first ART regimen until discontinued or amended and the reasons for the change. Survival analysis of durability was performed using Kaplan-Meyer curves analysis, and a Cox multiple regression model was constructed to identify associated factors. Results A first-line ART regimen was initiated for 600 patients; after 1 year, it had been changed in 172 (28%) cases, with a median duration of 31 months. The main reason for change was toxicity (20.5% of all patients), followed by loss to follow-up (8.3%) and virological failure (5.3%). The most common type of toxicity was gastrointestinal (30%), followed by cutaneous (23%) and neuropsychiatric (18%). The use of non-nucleoside reverse transcriptase inhibitors (NNRTIs) was associated with greater durability than that of protease inhibitors (43 months vs 21 months; P = .001). Conclusions The durability of the first-line ART regimen, based on current antiretroviral drugs and coformulations, is about 2.5 years, with toxicity being the main reason for its modification. Gastrointestinal toxicity is the type most commonly reported. NNRTI treatment is associated with greater durability of the first treatment regimen.

Hipertensión pulmonar en pacientes con infección por el virus de la inmunodeficiencia humana: papel del tratamiento antirretroviral

BACKGROUND AND OBJECTIVE Pulmonary arterial hypertension (PAH) is a serious disorder, more prevalent in patients infected with human immunodeficiency virus (HIV). It is not entirely clear what role is played by highly active antiretroviral therapy (HAART) in PAH development or course. Our aim was to describe PAH prevalence in a series of HIV-infected patients and identify possible links with cumulative and current use of different antiretrovirals. PATIENTS AND METHOD Cross-sectional study of a cohort of HIV-infected patients attending a hospital in southern Spain. Demographic data, data on HIV infection status and on cumulative and recent antiretroviral treatment were recorded. Transthoracic echocardiography was performed in all study participants. PAH was defined as pulmonary artery systolic pressure of 36mmHg or more. RESULTS A total of 400 patients participated in the study; 178 presented with tricuspid regurgitation and 22 of these presented with PAH (5.5%). No differences were encountered in age, sex, CD4 lymphocytes, proportion of naive patients or patients with AIDS. No differences were encountered in cumulative use of antiretrovirals. However, recent use of lamivudine was associated with a greater presence of PAH, whereas recent use of tenofovir and emtricitabine was associated with a lower presence of PAH. Logistic regression analysis was performed including the use of lamivudine, emtricitabine and tenofovir. Only recent use of tenofovir was associated with a lower presence of PAH (odds ratio 0.31; 95% confidence interval: 0.17-0.84). CONCLUSIONS PAH prevalence in our study was similar to others series. Current use of tenofovir may be associated with lower PAH prevalence.

Lipid changes in HIV-patients switching to the coformulated single tablet FTC/RPV/TDF (Eviplera®). Efficacy and safety analysis. GeSida Study 8114

Rilpivirine (RPV) has a better lipid profile than efavirenz (EFV) in naïve patients [ 1 ]. Switching to RPV may be convenient for many patients, while maintaining a good immunovirological control [ 2 ]. The aim of this study was to analyze lipid changes in HIV‐patients at 24 weeks after switching to Eviplera® (emtricitabine/RPV/tenofovir disoproxil fumarate [FTC/RPV/TDF]).

Left ventricular hypertrophy detected by echocardiography in HIV-infected patients

BACKGROUND Left ventricular hypertrophy (LVH) is a predictor of overall mortality in the general population. The most sensitive diagnostic method is transthoracic echocardiography (TTE). In this study, we describe the prevalence of LVH, and the factors associated with it, in a group of patients with HIV infection. METHODS TTE was offered to all patients attending the outpatient clinic of the Hospital Costa del Sol (Marbella, Spain) between 1 December 2009 and 28 February 2011. The corresponding demographic and clinical data were obtained. The left ventricular mass (LVM) was calculated and indexed by height(2.7). LVH was defined as LVM >48g/m(2.7) in men or >44g/m(2.7) in women. RESULTS We examined 388 individuals (75.5% male, mean age 45.38years). Of these, 76.1% were receiving HAART; 11.9% had hypertension, 6.2% had diabetes mellitus, 23.2% had dyslipidaemia and 53.6% were tobacco users. The risk of cardiovascular disease at 10years (RV10) was 12.15% (95%CI: 10.99-13.31%). 19.1% of these patients had a high RV10. A total of 69 patients (19.8%) presented high LVM. Age, hypertension, dyslipidaemia, RV10 and the use of nevirapine were associated with a greater presence of LVH in the univariate analysis. In the logistic regression analysis performed, the factors retained in the model were the presence of high RV10 (OR: 2.92, 95%CI: 1.39-6.15) and the use of nevirapine (OR 2.20, 95%CI: 1.18-4.14). CONCLUSIONS In this group of patients, the use of nevirapine and the presence of high RV10 were associated with LVH. The use of nevirapine might be related to its prescription for patients with higher RV10.

Seroprevalence of antibodies to the influenza A (H1N1) virus among healthcare workers prior to the 2009 pandemic peak.

Abstract Objective Our aim was to study the proportion of healthcare workers with a positive serology for Influenza A(H1N1)2009 without having flu, in a Spanish hospital at the beginning of the pandemic. Methods A survey study carried out during August 2009 (before the peak of the pandemic in Spain) in the Hospital Costa del Sol, a second level hospital with almost 300 beds in the South of Spain. The participants were workers in the following hospital units: Emergencies, Medical Area (Internal Medicine, Chest Diseases), Surgical Area (General Surgery and Anaesthesia) of any professional category. A study was made of the proportion of healthcare workers in our hospital with positive serology for the new influenza A (H1N1)2009 virus, as determined by the haemagglutination inhibition technique (≥1/40). The subjects completed a health status questionnaire, and provided a blood sample for serology testing. Results A total of 239 workers participated, of whom 25.1% had positive serology. The hospital area in which most individuals had positive serology was the Emergency Department (36.6%), while the professional category in which most individuals with a positive serology worked was that of the orderlies (41.7%). Conclusion Around 25% of healthcare workers in our hospital had positive serology before the peak of the pandemic, none of them had received vaccine for Influenza A (H1N1) 2009 or had been diagnosed of influenza previously.

Lipid Changes in Virologically Suppressed HIV-Infected Patients Switching from any Antiretroviral Therapy to the Emtricitabine/Rilpivirine/Tenofovir Single Tablet: GeSida Study 8114.

We carried out a retrospective, multicenter study of a cohort of 298 asymptomatic HIV-infected patients who switched from a regimen based on 2 nucleoside reverse transcriptase inhibitors + protease inhibitor (PI)/nonnucleoside reverse transcriptase inhibitor or ritonavir-boosted PI monotherapy to emtricitabine/rilpivirine/tenofovir disoproxil fumarate (FTC/RPV/TDF) to analyze lipid changes. At 24 weeks, 284 (95.3%) patients were still taking the same regimen, maintaining similar CD4 counts as at baseline (651 versus 672 cells/mm3, P = .08), and 98.9% of them with an undetectable viral load. Eight of the other 14 patients were lost to follow up and 6 (2.0%) ceased the new regimen: 3 due to adverse effects, 2 due to virologic failure, and 1 due to abandonment. The mean levels of fasting total cholesterol (TC), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C), and triglycerides fell at 12 and 24 weeks, with no changes detected in the TC to HDL-C ratio.

Raltegravir en pacientes con infección por el virus de la inmunodeficiencia humana y alto riesgo vascular

OBJECTIVES To record the experience with use of raltegravir (RTG) for devising highly active antiretroviral therapy (HAART) regimens based on RTG in high vascular risk patients. METHODS A retrospective study was conducted on high vascular risk patients taking RTG. Case was a patient who, at the time raltegravir was started, had ≥ 20% 10-year risk of cardiovascular disease, estimated by the algorithm of the European AIDS Clinical Society. Patients should have been on stable HAART including RTG for at least six months. A matched control with ≥ 20% risk of cardiovascular disease, was selected for each case. RESULTS Ten controls and ten cases were selected. After six months using RTG, a significant decreased was seen in levels of HDL cholesterol (median -2,5mg/dL in controls versus 2,5mg/dL in cases, p=0.015), triglycerides (10mg/dL versus -101 mg/dL, p=0.009), and TC/HDL-C ratio (0.17 versus -0.73, p=0.002). Ten-year risk of cardiovascular disease was -4.85% in cases versus -0.05% in controls (p=0.07). CONCLUSIONS RTG shows a good profile to be used in people with high vascular risk, with a decrease in TC/HDL-C ratio and vascular risk.

Primera pauta de tratamiento antirretroviral en pacientes con infección por el virus de la inmunodeficiencia humana. Durabilidad y factores asociados a su modificación

Objetivos Se evaluo la durabilidad de la primera pauta de tratamiento antirretroviral de gran actividad (TARGA) en pacientes sin tratamiento antirretroviral previo infectados por el virus de la inmunodeficiencia humana (VIH) y los factores asociados a su modificacion. Metodos Estudio multicentrico, retrospectivo, de pacientes con infeccion por el VIH que iniciaron su primer TARGA entre 1997 y 2003. La variable principal medida fue la durabilidad de la primera pauta de TARGA hasta su cambio. Se realizo estadistica descriptiva, curvas de Kaplan-Meier para evaluar la durabilidad y se construyo un modelo de regresion multiple de Cox para valorar los factores asociados a la durabilidad. Resultados Iniciaron su primer TARGA 603 pacientes y 130 (21,6%) lo mantuvieron hasta la visita final, con una mediana de duracion de 17,5 meses. Un 36% de los pacientes interrumpio el tratamiento antes del ano. Cuando se excluyeron las causas “no desfavorables” (simplificacion/interrupcion estructurada), la mediana de duracion aumento hasta los 2 anos. La causa principal del cambio fue la toxicidad (25%), seguida de la simplificacion (19%) y el fracaso virologico (15%). Se encontro una mayor durabilidad de las pautas con un inhibidor de la transcriptasa inversa no analogo de nucleosidos (ITINAN) (p Conclusion La mediana de duracion del primer TARGA fue algo menor de 1,5 anos y la causa principal del cambio fue la toxicidad. Se constata una mayor durabilidad de las pautas con ITINAN que, al menos en parte, podria explicarse por su menor numero de comprimidos.